Can You Get Pregnant During Perimenopause?

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Think perimenopause means the end of your baby-making days? Think again! Getting pregnant during perimenopause is possible. Whether that plus sign on a pregnancy test is good or bad news depends on your perspective! 

Perimenopause marks the transition period leading up to menopause, typically beginning in a woman’s 40s. Perimenopause is characterized by erratic menstrual periods and signs and symptoms like hot flashes, night sweats, and brain fog. While fertility declines during this phase, pregnancy is still possible. In this article, let’s look at fertility and pregnancy in perimenopause in more depth.

Perimenopause is a time when hormone levels fluctuate as the ovaries gradually produce less estrogen. This transition usually lasts several years before menstrual periods stop. The point when it’s been a whole year since the last period is considered “menopause.”

During perimenopause:

• Ovulation becomes less frequent and more unpredictable
• Periods often become irregular or skip months
• Fertility declines, but pregnancy is still possible
• The transition can last anywhere from 2 to 10 years

During perimenopause, your body is still capable of releasing eggs and potentially becoming pregnant. However, several factors make conception more challenging during this time.

• Declining egg quality and quantity: As you age, the number and quality of your eggs decrease. By perimenopause, the remaining eggs are often less viable for fertilization and healthy embryo development.
• Irregular ovulation: Hormonal fluctuations lead to unpredictable ovulation cycles. You may go months without ovulating, then suddenly release an egg.
• Uterine changes: The uterine lining may thin out, making it more difficult for a fertilized egg to implant successfully.
• Other health conditions: Certain health issues that are more common in midlife –  including uterine fibroids, endometriosis, and hypothyroidism – can adversely affect your fertility.

While pregnancy is possible during perimenopause, the chances are significantly lower compared to younger women. Here are some statistics to consider:

• If you’re between the ages of 40 and 44, you have about a 10 to 20% chance of getting pregnant within one year of regular unprotected sex.
• From age 45 to 49, the pregnancy rate drops to around 12% after one year.
• By age 50, your probability of natural conception is less than 1%.

It’s important to note that these are general statistics. Individual factors like your overall health, genetics, and lifestyle also influence your fertility.

Another factor that can affect your pregnancy chances in perimenopause is the presence of autoimmune Hashimoto’s thyroiditis or hypothyroidism. Not only are these thyroid conditions more frequently diagnosed during perimenopause, but they can adversely affect your fertility. If you have Hashimoto’s or hypothyroidism and are in perimenopause, you’ll want to understand how these conditions interact if you are interested in becoming pregnant.  

The thyroid and reproductive health

Thyroid hormones play a crucial role in your reproductive health. They help regulate the menstrual cycle, support ovulation, and maintain a healthy uterine lining. An imbalance in thyroid hormones, whether due to autoimmune Hashimoto’s disease or other factors, can lead to irregular cycles, amenorrhea (absence of periods), anovulation (lack of ovulation), and issues with the endometrial lining. All of these situations can make conception more difficult.

Hypothyroidism and fertility during perimenopause

Hypothyroidism can also cause hormonal imbalances that impair fertility. Specifically, it can cause elevated prolactin levels, which inhibit FSH and LH, hormones needed for egg maturation and to trigger ovulation. An underactive thyroid can also disrupt estrogen and progesterone production and metabolism.

Symptoms of hypothyroidism, such as fatigue and weight gain, can also worsen during perimenopause, making it harder to maintain a healthy weight and manage overall health, which are important for fertility.

Over 50% of women with hypothyroidism experience abnormal menstrual cycles and disrupted ovulation. Perimenopause can make periods even more irregular, preventing the release of eggs from the ovaries (anovulation) and leading to irregular or heavy menstrual bleeding. These ovulatory and menstrual disturbances can make it more difficult to conceive.

There is some evidence that hypothyroidism may negatively affect egg quality, which is already declining during perimenopause. Poor egg quality reduces the chances of successful fertilization and implantation.

Thyroid conditions can also complicate assisted reproduction. For perimenopausal women using assisted reproductive technologies:

• Thyroid autoimmunity is associated with lower success rates in IVF
• Women with thyroid issues undergoing IVF have a higher risk of developing overt hypothyroidism after ovarian stimulation

Even if conception occurs, hypothyroidism is associated with a higher risk of miscarriage. Miscarriage rates are 6 to 15% in women with hypothyroidism, compared to 2.2% in women without thyroid issues.

Hashimoto’s and fertility during perimenopause

The primary cause of hypothyroidism in the U.S. is autoimmune Hashimoto’s thyroiditis. Hashimoto’s can have significant effects on the menstrual cycle and fertility during perimenopause. Some of the effects include:

Autoimmune Hashimoto’s thyroiditis can cause dysregulated menstrual cycles during perimenopause. Thyroid autoimmunity, even in the absence of overt thyroid dysfunction, is associated with menstrual irregularities during perimenopause. Specifically:

• More frequent anovulatory cycles
• Irregular menstrual bleeding patterns
• Shorter or longer menstrual cycles
• Amenorrhea (absence of menstruation)

Thyroid autoimmunity can also worsen the hormonal fluctuations already occurring during perimenopause, further contributing to menstrual cycle irregularities and symptoms. Autoimmune thyroid disease:

• May contribute to relative estrogen dominance
• May cause progesterone levels to decline more rapidly
• Can disrupt FSH and LH production and signaling

Increased inflammation: The autoimmune process involved in thyroid autoimmunity leads to increased inflammation, which can affect the menstrual cycle.

• Higher levels of inflammatory cytokines may interfere with normal ovarian function
• Inflammation can disrupt the delicate balance of reproductive hormones
• This may lead to heavier or more painful periods in some women

Some evidence suggests that thyroid autoimmunity may accelerate or exacerbate perimenopausal symptoms related to menstrual cycles, including:

• More severe or frequent hot flashes
• Increased menstrual cramping or discomfort
• Greater mood swings associated with hormonal fluctuations

Finally, there is some indication that thyroid autoimmunity may negatively impact ovarian reserve during perimenopause. It’s thought that autoimmune thyroid disease could potentially accelerate the decline in egg quantity and quality, leading to earlier onset of menstrual irregularities, problems with ovulation, and eventual cessation of periods. More research is needed to better understand this relationship.

If you do become pregnant, it’s also important to be aware that autoimmune thyroid disease (even with normal thyroid hormone levels) increases miscarriage risk four-fold.

Diagnosis of thyroid conditions

Accurate diagnosis of thyroid disorders is essential for effective management and improving fertility outcomes. You’ll need to conduct thyroid function tests measuring levels of thyroid-stimulating hormone (TSH), free thyroxine (T4), and free triiodothyronine (T3) to help determine thyroid function. It’s also essential to test for thyroid peroxidase (TPO) antibodies to confirm whether there’s autoimmune involvement. (Paloma Health’s complete home thyroid test kit panel lets you test for  TSH, free  T4, free T3, and TPO antibodies from the convenience of home.)  

Managing Hashimoto’s and hypothyroidism

Effective management of thyroid disorders involves a combination of medication, lifestyle adjustments, and regular monitoring.

The primary treatment for hypothyroidism is thyroid hormone replacement medication to normalize thyroid hormone levels. Proper dosage adjustments are crucial, especially during perimenopause, to ensure optimal thyroid function and fertility.

In addition, it’s essential to eat a balanced diet rich in iodine, selenium, and zinc to support thyroid health. Avoiding excessive soy products and gluten can also be beneficial for some women with autoimmune thyroid disease.

Regular physical activity helps manage weight and reduce stress, and both approaches can positively impact thyroid function and overall health.

Stress can worsen autoimmune conditions and thyroid dysfunction. Techniques such as meditation, yoga, and counseling can help manage stress levels.

When hypothyroidism is treated, it can improve fertility outcomes. In women who had not yet started their perimenopause, over 75% of infertile women with hypothyroidism were able to conceive within one year after beginning thyroid treatment. And there’s more good news! Thyroid hormone replacement treatment may improve pregnancy rates and reduce miscarriage risk in women with subclinical hypothyroidism or thyroid autoimmunity.

Regular follow-up with a healthcare provider is essential for adjusting thyroid medication dosages and monitoring thyroid function. Routine blood tests can help ensure that thyroid hormone levels are within the optimal range for fertility. Paloma members can get Paloma’s complete home blood test kit for easy at-home thyroid testing and access virtual visits with thyroid-savvy healthcare providers for diagnosis and treatment.

Despite lower fertility, contraception is still recommended if you want to avoid pregnancy during your perimenopause. The Faculty of Sexual and Reproductive Healthcare (FSRH) provides the following guidelines:

• If you’re under 50, use contraception for at least two years after your last period
• If you’re over 50, use contraception for at least one year after your last period
• At age 55, you can stop using contraception even with occasional periods, as pregnancy is extremely rare

Types of contraception

You should discuss contraceptive options with your healthcare provider, as some methods may offer additional benefits, such as helping manage perimenopausal symptoms. Several types of contraception are recommended for women during perimenopause:

• Long-acting reversible contraceptives (LARCs), which include the copper intrauterine device (IUD) and hormonal intrauterine systems (IUS) like Mirena.
• Progestogen-only methods, like the progestogen-only pill (“mini-pill”), the progestogen implant (e.g., Nexplanon), and the progestogen-only injectable, like Depo-Provera. (Note: this may not be the first choice for women over 40 with osteoporosis risk factors.)
• Barrier methods, such as condoms with spermicide foam
• Combined hormonal contraceptives (CHC), including the combined oral contraceptive pill, the patch, and the vaginal ring. (Note: CHCs are generally not recommended for women over 50 due to increased health risks.)
• Permanent methods, including sterilization or vasectomy for a male partner.

Factors to consider

What factors should you consider when using contraception during perimenopause?

• Safety and appropriateness, as your risks may change with age
• Medical eligibility criteria, as comorbidities are more common
• Non-hormonal methods like copper IUDs, which allow you to track natural menstrual changes
• Whether the chosen hormonal method could potentially help manage your perimenopausal symptoms

The best option for you depends on your health, preferences, and needs. Consulting with a healthcare provider is recommended to determine the most suitable contraceptive method during your perimenopausal transition.

If you want to get pregnant and are in perimenopause, your first step should be to consult your healthcare provider. They can:

• Conduct hormone tests to assess your fertility status and thyroid function
• Screen for other potential health issues affecting your fertility
• Discuss appropriate fertility treatment options
• Address any concerns about pregnancy risks

Some women take hormone replacement therapy (HRT) to manage perimenopausal symptoms. If you’re on HRT and want to conceive, be sure that you discuss this with your doctor. While HRT is generally considered safe and doesn’t usually reduce conception chances, your doctor may recommend adjustments to your treatment plan.

You may also want to consult with a reproductive endocrinologist or fertility specialist, who can provide tailored treatment plans and additional options, such as fertility medications or interventions, to enhance your chances of conception.

While pregnancies can be successful during perimenopause, they do come with increased risks, including:

• Higher chance of miscarriage: The risk of miscarriage increases with maternal age, mainly due to chromosomal abnormalities in eggs.
• Gestational diabetes and hypertension: Older mothers have a higher likelihood of developing these conditions during pregnancy.
• Multiple pregnancies: Hormonal changes can sometimes cause the release of multiple eggs, increasing the chance of twins.
• Genetic disorders: The risk of chromosomal abnormalities like Down syndrome increases with maternal age.

Fertility treatments and perimenopause

If you’re in perimenopause and actively trying to conceive, fertility treatments may be an option. However, success rates do decline with age. The American Society for Reproductive Medicine notes that by age 40, the chance of getting pregnant during each menstrual cycle is less than 5%, even with fertility treatments.

If you’re considering fertility treatments, consult a specialist as early as possible. They can assess your individual situation and discuss options like:

• Ovulation induction: This involves taking medications like clomiphene citrate or gonadotropins to stimulate egg production.
• Intrauterine insemination (IUI): IUI involves placing sperm directly into the uterus, which can be beneficial for women with irregular cycles or other fertility issues.
• In vitro fertilization (IVF): IVF can help bypass some of the fertility challenges by fertilizing an egg outside the body and implanting the embryo into the uterus.
• Egg donation: Use of a donor egg by another woman who cannot use her own eggs for conception.

When you’re in perimenopause, it can sometimes be confusing to determine if you’re pregnant. Some symptoms of early pregnancy can mimic perimenopausal symptoms, making it challenging to distinguish between the two. Common overlapping symptoms include:

• Missed or irregular periods
• Breast tenderness
• Mood swings
• Fatigue

If you’re trying to conceive and experience these symptoms, it’s worth taking a home pregnancy test or consulting your doctor, especially if your periods have been irregular.

While fertility declines during perimenopause, pregnancy remains possible until you’ve reached menopause (defined as 12 consecutive months without a period). Whether you’re hoping to conceive or want to avoid pregnancy, it’s crucial to understand your body’s changes during this transition. This is especially important if you’re a woman with Hashimoto’s hypothyroidism in perimenopause.

Remember, every woman’s experience with perimenopause is unique. Regular check-ups with your healthcare provider can help you navigate this phase of life, addressing your hormonal health and overall well-being. Whether you’re considering pregnancy or not, staying informed and proactive about your health during perimenopause is vital to making the best decisions for your individual circumstances.

And don’t forget that navigating fertility and potential pregnancy during perimenopause can be emotionally challenging. Whether you’re hoping to conceive or want to avoid pregnancy, the uncertainty of this transitional period can cause stress and anxiety. Don’t hesitate to seek support from your healthcare provider, a counselor, or support groups.

Paloma Health members receive specialized, compassionate care to navigate perimenopause and hypothyroidism. As these conditions often overlap, Paloma Health’s team of expert providers provides personalized treatment plans that address your unique hormonal imbalances. With convenient virtual consultations, comprehensive thyroid testing, and a focus on integrative care, Paloma ensures that you receive the support you need to manage your reproductive and thyroid health and empowers you to regain control of your wellness and thrive during this stage of life.

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